Practice Questions : NEURO A.

Maintaining the neck in a neutral

position.
Increased ICP - RNPEDIA B. Keeping the head in a midline position.
C. Elevating the head of the bed between 30
to 45 degrees.
1. Nurse Mike is monitoring a male client D. Turning the head to one side.
who was brought to the emergency
department after a motor vehicle accident. 5. Nurse Alex is assessing the motor
The nurse begins to suspect increasing function of an unconscious client and needs
intracranial pressure (ICP) when noticing to test the client's peripheral response to
which of the following signs? pain. Which method should Nurse Alex use?

A. The client is oriented when awakened A. Sternal rub.

but immediately falls back asleep. B. Nail bed pressure.
B. The client refuses dinner due to a lack of C. Squeezing the sternocleidomastoid
appetite. muscle.
C. The client's blood pressure has dropped D. Pressure on the orbital rim.
from 160/90 to 110/70.
D. The client's pulse has increased from 88 6. Nurse Emily is monitoring a 4-year-old
to 96 with occasional skipped beats. child in the emergency department for signs
of increased intracranial pressure (ICP) after
a fall from a bicycle that resulted in head
2. Nurse Rachel is assisting with caloric trauma. Which of the following signs would
testing of the oculovestibular reflex in an raise concern for increased ICP?
unconscious client. After cold water is
injected into the left ear, the client shows A. A bulging anterior fontanel.
eye movements toward the left, followed by B. Repeated episodes of vomiting.
rapid nystagmus toward the right. The nurse C. Difficulty reading short words from 18
recognizes that this finding indicates: inches away.
D. Feeling sleepy at 10 PM.
A. A cerebral lesion.
B. A temporal lesion. 7. Nurse Jenna is preparing medications for
C. Brain death. a patient with increased intracranial pressure
D. An intact brainstem. (ICP). Which type of drug might be
administered to help manage this condition?
3. Nurse Sarah is caring for a client with a
head injury and monitoring for increased A. Carbonic anhydrase inhibitors
intracranial pressure (ICP). The client’s B. Histamine receptor blockers
blood pressure is 90/60 mmHg, and his ICP C. Anticholinergics
is 18 mmHg. Based on these values, what is D. Barbiturates
the client’s cerebral perfusion pressure
(CPP)? 8. Nurse Linda is caring for a patient with
increased intracranial pressure (ICP). Which
A. 48 mm Hg intervention should the nurse avoid to
B. 88 mm Hg prevent further increases in ICP?
C. 68 mm Hg
D. 52 mm Hg A. Administer stool softeners as prescribed.
4. Nurse Amy is caring for a female patient B. Elevate the head of the bed to 30 degrees.
with increased intracranial pressure (ICP). C. Suction the patient frequently to
As she adjusts the patient's position, she maintain a clear airway.
ensures proper alignment to prevent any D. Keep the patient's neck in a neutral
further elevation in ICP. Which position position.
should Nurse Amy avoid for this patient?
9. Nurse Lisa is caring for a male patient (ICP) who is intubated and on mechanical
with suspected increased intracranial ventilation. To prevent further increases in
pressure (ICP). While setting respiratory ICP during suctioning, which drug would
goals to help manage the patient's condition, the nurse anticipate administering
which of the following is the most endotracheally before the procedure?
appropriate objective?
A. Furosemide (Lasix)
A. Keep the partial pressure of arterial B. Phenytoin (Dilantin)
oxygen (PaO2) above 80 mm Hg. C. Mannitol (Osmitrol)
B. Prevent the development of respiratory D. Lidocaine (Xylocaine)
alkalosis.
C. Encourage effective elimination of 14. Nurse Laura is caring for a client with a
carbon dioxide. subdural hematoma who becomes restless
D. Aim to lower the arterial pH. and confused, with dilation of the ipsilateral
pupil. The physician orders mannitol. For
what purpose is mannitol prescribed in this
10. Nurse Taylor is assessing a patient who case?
was admitted after a head injury from a car
accident. While monitoring for signs of A. To prevent acute tubular necrosis.
increased intracranial pressure (ICP), she B. To promote osmotic diuresis and
remains alert for early indicators. Which of reduce ICP.
the following would most likely be the first C. To lower intraocular pressure.
sign to appear? D. To draw water into the vascular system to
raise blood pressure.
A. A widening of the pulse pressure.
B. Excessive output of very dilute urine. 15. Nurse Amy is evaluating a client with a
C. Onset of restlessness and confusion. subdural hematoma who was given mannitol
D. A noticeable decrease in heart rate to lower intracranial pressure (ICP). Which
(bradycardia). of the following findings would best indicate
that the mannitol is effective?

11. Nurse Sarah is closely monitoring a A. Pupils are 8 mm and nonreactive.

patient with a severe head injury for signs of B. Urine output increases.
increasing intracranial pressure (ICP). C. Systolic blood pressure remains at 150
Which of the following findings is the most mm Hg.
indicative of rising ICP? D. BUN and creatinine levels return to
normal.
A. Episodes of intermittent tachycardia.
B. Heightened restlessness 16. Nurse Julia is monitoring a client with
C. Excessive thirst (polydipsia) increased intracranial pressure (ICP). Which
D. Rapid breathing (tachypnea) of the following trends in vital signs would
indicate that ICP is rising?
12. Nurse Olivia is assessing a patient who
is experiencing difficulties with memory and A. Decreasing temperature, increasing pulse,
learning. These issues are most likely related decreasing respirations, increasing blood
to which lobe of the brain? pressure.
B. Increasing temperature, decreasing
A. Frontal pulse, decreasing respirations, increasing
B. Temporal blood pressure.
C. Occipital C. Decreasing temperature, decreasing
D. Parietal pulse, increasing respirations, decreasing
blood pressure.
13. Nurse Karen is caring for a female
patient with increased intracranial pressure
D. Increasing temperature, increasing pulse, D. Tonic-clonic seizure.
increasing respirations, decreasing blood
pressure. 21. Nurse Megan is preparing a client for a
lumbar puncture. In which position should
17. Nurse Clara is educating the family of a the nurse place the client for the procedure?
patient who recently suffered a concussion
about the early signs of increased A. Prone, with a pillow under the abdomen.
intracranial pressure (ICP). Which of the B. Prone, in a slight Trendelenburg position.
following would she identify as an early C. Side-lying, with legs pulled up and
indicator? head bent down onto the chest.
D. Side-lying, with a pillow under the hip.
A. A drop in systolic blood pressure. 22. Nurse James is assessing a client who
B. The patient cannot be awakened by reports being unable to feel the temperature
noxious stimuli. of a hot oven while cooking. Which lobe of
C. Pupils that are dilated and unresponsive the brain might be dysfunctional in this
to light. case?
D. Headache accompanied by vomiting.
A. Frontal
B. Occipital
C. Parietal
18. Nurse Sarah is reviewing normal D. Temporal
intracranial pressure (ICP) values while
caring for a patient in the ICU. Which of the 23. Nurse Carla is monitoring a patient for
following is considered a normal range for signs of worsening increased intracranial
ICP? pressure (ICP). As she observes the patient,
she knows that later signs of ICP typically
A. 25 mm Hg include which of the following?
B. 35 to 45 mm Hg
C. 120/80 mm Hg A. A rise in pulse rate.
D. 0 to 15 mm Hg B. A drop in blood pressure.
C. Projectile vomiting.
19. Nurse Jordan is reviewing symptoms of D. A narrowing of the pulse pressure.
increased intracranial pressure (ICP) with a
patient diagnosed with a brain tumor. 24. Nurse Kelly is monitoring a patient after
Whether benign or malignant, the tumor head trauma for signs of increased
could eventually raise ICP. Which of the intracranial pressure (ICP). Which of the
following is not typically associated with following signs would most likely appear
signs of increased ICP? first?

A. Headache, nausea, and vomiting. A. A decrease in heart rate (bradycardia).

B. A rise in pulse rate with a drop in B. Large amounts of very dilute urine.
blood pressure. C. Restlessness and confusion.
C. Papilledema, dizziness, and changes in D. A widening of the pulse pressure.
mental status.
D. Clear motor deficits. 25. Nurse Angela is caring for a client
admitted with a subarachnoid hemorrhage
20.Nurse Julia is caring for a patient with a who reports a severe headache, neck
phenytoin level of 32 mg/dl, which is above stiffness (nuchal rigidity), and projectile
the therapeutic range. Which of the vomiting. The nurse understands that a
following symptoms might she observe? lumbar puncture (LP) would be
contraindicated in which of the following
A. Ataxia and confusion. situations?
B. Urinary incontinence.
C. Sodium depletion.
A. The client requires mechanical finding indicates damage to which part of
ventilation. the brain?
B. The vomiting continues. a. Diencephalon
C. Blood is expected in the cerebrospinal b. Medulla
fluid (CSF). c. Midbrain
D. Intracranial pressure (ICP) is elevated. d. Cortex

6. If a male client experienced a

cerebrovascular accident (CVA) that
HALO HALO NA TOPICS NEURO damages the hypothalamus, the nurse would
anticipate that the client has problems wit
a. body temperature control.
1. A female client admitted to an acute care b. balance and equilibrium
facility after a car accident develops signs c. visual acuity
and symptoms of increased intracranial d. thinking and reasoning
pressure (ICP). The client is intubated and
placed on mechanical ventilation to help 7. Which nursing diagnosis takes highest
reduce ICP. To prevent a further rise in ICP priority for a client with Parkinson’s Crisis?
caused by suctioning, the nurse anticipates a. Imbalanced nutrition: Less than body
administering which drug endotracheally requirements
before suctioning? b. Ineffective airway clearance
a. phenytoin (Dilantin) c. Impaired urinary elimination
b. mannitol (Osmitrol) d. Risk for injury
c. lidocaine (Xylocaine)
d. furosemide (Lasix 7. A female client complains of periorbital
aching, tearing, blurred vision, and
2. After striking his head on a tree while photophobia in her right eye.
falling from a ladder, a young man age Ophthalmologic examination reveals a
18 is admitted to the emergency department. small,irregular, nonreactive pupil — a
He’s unconscious and his pupils are condition resulting from acute iris
nonreactive. Which intervention would be inflammation (iritis). As part of the client’s
the most dangerous for the client? therapeutic regimen, the physician prescribe
a. Give him a barbiturate atropine sulfate (Atropisol), two drops of
b. Place him on mechanical ventilation. 0.5% solution in the right eye twice daily.
c. Perform a lumbar puncture. Atropine sulfate belongs to which drug
d. Elevate the head of his bed. classification?
a. Parasympathomimetic agent
4. When obtaining the health history from a b. Sympatholytic agent
male client with retinal detachment,the nurse c. Adrenergic blocker
expects the client to report d. Cholinergic blocker
a. light flashes and floaters in front of the
eye. 8. A female client who’s paralyzed on the
b. a recent driving accident while changing left side has been receiving physical
lanes. therapy and attending teaching sessions
c. headaches, nausea, and redness of the about safety. Which behavior indicates that
eyes. the client accurately understands safety
d. frequent episodes of double vision measures related to paralysis?
a. The client leaves the side rails down.
5. A female client who was trapped inside a b. The client uses a mirror to inspect the
car for hours after a head-on collision is skin.
rushed to the emergency department with c. The client repositions only after being
multiple injuries. During The neurologic reminded to do so.
examination, the client responds to painful d. The client hangs the left arm over the side
stimuli with decerebrate posturing. This of the wheelchair.
 client’s oculocephalic (doll’s eye) response
9. A male client in the emergency by:
department has a suspected neurological a. introducing ice water into the external
disorder. To assess gait, the nurse asks the auditory canal.
client to take a few steps; with each b. touching the cornea with a wisp of cotton.
step, the client’s feet make a half circle. To c. turning the client’s head suddenly while
document the client’s gait, the nurse holding the eyelids open.
should use which term? d. shining a bright light into the pupil
a. Ataxic
b. Dystrophic 14. While reviewing a client’s chart, the
c. Helicopod nurse notices that the female client has
d. Steppage myasthenia gravis. Which of the following
statements about neuromuscular blocking
10. A physician diagnoses a client with agents is true for a client with this
myasthenia gravis, prescribing condition?
pyridostigmine (Mestinon), 60 mg P.O. a. The client may be less sensitive to the
every 3 hours. Before administering this effects of a neuromuscular blocking agent.
anticholinesterase agent, the nurse reviews b. Succinylcholine shouldn’t be used;
the client’s history. Which pancuronium may be used in a lower
pre existing condition would contraindicate dosage.
the use of pyridostigmine? c. Pancuronium shouldn’t be used;
a. Ulcerative colitis succinylcholine may be used in a lower
b. Blood dyscrasia dosage.
c. Intestinal obstruction d. Pancuronium and succinylcholine both
d. Spinal cord injury require cautious administration

11. Nurse Oliver is monitoring a client for 15. The nurse is assessing a 37-year-old
adverse reactions to dantrolene(Dantrium). client diagnosed with multiple sclerosis.
Which adverse reaction is most common? Which of the following symptoms would the
a. Excessive tearing nurse expect to find?
b. Urine retention. a. Vision changes
c.Muscle weakness b. Absent deep tendon reflexes
d. Slurred speech c. Tremors at rest
d. Flaccid muscles
12. A male client has a history of painful, 16. During recovery from a cerebrovascular
continuous muscle spasms. He has taken accident (CVA), a female client is given
several skeletal muscle relaxants without nothing by mouth, to help prevent
experiencing relief. Hisphysician prescribes aspiration. To determine when the client is
diazepam (Valium), 2 mg P.O. twice daily. ready for a liquid diet, the nurse assesses the
In addition to being used to relieve painful client’s swallowing ability once each shift.
muscle spasms, diazepam also is This assessment evaluates:
recommended for: a. cranial nerves I and II.
a. long-term treatment of epilepsy. b. cranial nerves III and V.
b. postoperative pain management of c. cranial nerves VI and VIII.
laminectomy clients. d. cranial nerves IX and X
c. postoperative pain management of
diskectomy clients
d. treatment of spasticity associated with Nurse Carol is assessing a client with
spinal cord lesions Parkinson’s disease. The nurse recognize
bradykinesia when the client exhibits:
13. A female client who was found a. Intentional tremor
unconscious at home is brought to the b. Paralysis of limbs
hospital by a rescue squad. In the intensive c. Muscle spasm
care unit, the nurse checks the d. Lack of spontaneous movement
 A. “You may have difficulty believing
A client who suffered from automobile this, but the paralysis caused by
accident complains of seeing frequent
this disease is temporary.”
flashes of light. The nurse should expect:
a. Myopia B. “You’ll have to accept the fact that
b. Detached retina you’re permanently paralyzed.
c. Glaucoma However, you won’t have any
d. Scleroderma sensory loss.”
C. “It must be hard to accept the
Kate with severe head injury is being
monitored by the nurse for increasing permanency of your paralysis.”
intracranial pressure (ICP). Which finding
should be most indicative sign of increasing D. “You’ll first regain use of your legs
intracranial pressure? and then your arms.”
a. Intermittent tachycardia
b. Polydipsia The nurse is working on a surgical floor.
c. Tachypnea The nurse must logroll a male client
d. Increased restlessness
following a:

A white female client is admitted to an acute A. laminectomy.

care facility with a diagnosis of B. thoracotomy.
cerebrovascular accident (CVA). Her history
C. hemorrhoidectomy.
reveals bronchial asthma, exogenous
D. cystectomy.
obesity, and iron deficiency anemia. Which
history finding is a risk factor for CVA? A female client with a suspected brain tumor
is scheduled for computed tomography
A. Caucasian race
(CT). What should the nurse do when
B. Female sex
preparing the client for this test?
C. Obesity
D. Bronchial asthma A. Immobilize the neck before the client
is moved onto a stretcher.
The nurse is teaching a female client with
B. Determine whether the client is
multiple sclerosis. When teaching the client
allergic to iodine, contrast dyes, or
how to reduce fatigue, the nurse should tell
shellfish.
the client to:
C. Place a cap over the client’s head.

A. take a hot bath. D. Administer a sedative as ordered.

B. rest in an air-conditioned room.
C. increase the dose of muscle During a routine physical examination to
relaxants.
assess a male client’s deep tendon reflexes,
D. avoid naps during the day.
the nurse should make sure to:
A female client with Guillain Barré
A. use the pointed end of the reflex
syndrome has paralysis affecting the
hammer when striking the Achilles
respiratory muscles and requires mechanical
tendon.
ventilation. When the client asks the nurse
B. support the joint where the tendon
about the paralysis, how should the nurse
is being tested.
respond?
C. tap the tendon slowly and softly
D. hold the reflex hammer tightly.
A female client is admitted in a disoriented A female client admitted to the hospital with
and restless state after sustaining a a neurological problem asks the nurse
concussion during a car accident. Which whether magnetic resonance imaging may
nursing diagnosis takes highest priority in be done. The nurse interprets that the client
this client’s plan of care? may be ineligible for this diagnostic
procedure based on the client’s history of:
A. Disturbed sensory perception
(visual) A. Hypertension
B. Self-care deficient: B. Heart failure
C. Prosthetic valve replacement
Dressing/grooming D. Chronic obstructive pulmonary
C. Impaired verbal communication disorder
D. Risk for injury

For a male client with suspected increased

intracranial pressure (ICP), a most A male client is having a lumbar puncture

appropriate respiratory goal is to: performed. The nurse would plan to place
the client in which position?
A. prevent respiratory alkalosis.
A. Side-lying, with a pillow under the
B. lower arterial pH.
hip
C. promote carbon dioxide
B. Prone, with a pillow under the
elimination.
abdomen
D. maintain partial pressure of arterial
oxygen (PaO2) above 80 mm Hg C. Prone, in slight-Trendelenburg’s
position
Nurse Mary witnesses a neighbor’s husband D. Side-lying, with the legs pulled up
sustain a fall from the roof of his house. The and head bent down onto chest.
nurse rushes to the victim and determines
the need to opens the airway in this victim The nurse is positioning the female client

by using which method? with increased intracranial pressure. Which

of the following positions would the nurse
A. Flexed position avoid?
B. Head tilt-chin lift
A. Head mildline
C. Jaw thrust maneuver
D. Modified head tilt-chin lift B. Head turned to the side
C. Neck in neutral position
12. The nurse is assessing the motor
function of an unconscious male client. The D. Head of bed elevated 30 to 45

nurse would plan to use which plan to use degrees

which of the following to test the client’s

A female client has clear fluid leaking from
peripheral response to pain?
the nose following a basilar skull fracture.

A. Sternal rub The nurse assesses that this is cerebrospinal

B. Nail bed pressure fluid if the fluid:
C. Pressure on the orbital rim
D.Squeezing of the A. Is clear and tests negative for
sternocleidomastoid muscle glucose
 B. Is grossly bloody in appearance B. Thickening liquids to the
and has a pH of 6 consistency of oatmeal
C. Clumps together on the dressing C. Placing food on the unaffected side
and has a pH of 7 of the mouth
D. Separates into concentric rings D. Allowing plenty of time for chewing
and test positive of glucose and swallowing

A male client with a spinal cord injury is The nurse is assessing the adaptation of the
prone to experiencing automatic dysreflexia. female client to changes in functional status
The nurse would avoid which of the after a brain attack (stroke). The nurse
following measures to minimize the risk of assesses that the client is adapting most
recurrence? successfully if the client:

A. Strict adherence to a bowel A. Gets angry with family if they

retraining program interrupt a task
B. Keeping the linen wrinkle-free B. Experiences bouts of depression and
under the client irritability
C. Preventing unnecessary pressure C. Has difficulty with using modified
on the lower limbs feeding utensils
D. Limiting bladder D. Consistently uses adaptive
catheterization to once every 12 equipment in dressing self
hours
Nurse Kristine is trying to communicate
The nurse is assigned to care for a female with a client with brain attack (stroke) and
client with complete right sided hemiparesis. aphasia. Which of the following actions by
The nurse plans care knowing that this the nurse would be least helpful to the
condition: client?

A. The client has complete bilateral A. Speaking to the client at a slower rate
paralysis of the arms and legs. B. Allowing plenty of time for the
B. The client has weakness on the client to respond
right side of the body, C. Completing the sentences that the
including the face and tongue. client cannot finish
C. The client has lost the ability to
D. Looking directly at the client during
move the right arm but is able to
attempts at speech
walk independently.
D. The client has lost the ability to A female client has experienced an episode
move the right arm but is able to of myasthenic crisis. The nurse would assess
walk independently. whether the client has precipitating factors
such as:
20. The client with a brain attack (stroke)
has residual dysphagia. When a diet order is A. Getting too little exercise
initiated, the nurse avoids doing which of B. Taking excess medication
the following?
C. Omitting doses of medication

A. Giving the client thin liquids D. Increasing intake of fatty foods

24. The nurse is teaching the female client D. Providing intravenously administered
with myasthenia gravis about the prevention sedatives, reducing distractions and limiting
of myasthenic and cholinergic crises. The visitors
nurse tells the client that this is most
effectively done by:

A male client has an impairment of cranial

A. Eating large, well-balanced meals
nerve II. Specific to this impairment, the
B. Doing muscle-strengthening
nurse would plan to do which of the
exercises
following to ensure client to ensure client
C. Doing all chores early in the day
safety?
while less fatigued
D. Taking medications on time to A. Speak loudly to the client
maintain therapeutic blood levels B. Test the temperature of the shower
water
C. Check the temperature of the food
on the delivery tray.
D. Provide a clear path for
Female client is admitted to the hospital
ambulation without obstacles
with a diagnosis of Guillain-Barre
syndrome. The nurse inquires during the 30. A female client has a neurological deficit
nursing admission interview if the client involving the limbic system. Specific to this
has history of: type of deficit, the nurse would document
which of the following information related
A. Seizures or trauma to the brain
to the client’s behavior.
B. Meningitis during the last 5 years
C. C. Back injury or trauma to the A. Is disoriented to person, place, and
spinal cord time
D. Respiratory or gastrointestinal B. Affect is flat, with periods of
infection during the previous emotional lability
month. C. Cannot recall what was eaten for
breakfast today
A female client with Guillain Barre
D. Demonstrate inability to add and
syndrome has ascending paralysis and is
subtract; does not know who is
intubated and receiving mechanical
president
ventilation. Which of the following
strategies would the nurse incorporate in the If a male client experienced a
plan of care to help the client cope with this cerebrovascular accident (CVA) that
illness? damaged the hypothalamus, the nurse would
anticipate that the client has problems with:
A. Giving client full control over care
decisions and restricting visitors A. body temperature control.
B. Providing positive feedback and B. balance and equilibrium.
encouraging active range of motion C. C. visual acuity.
Providing information, giving positive D. thinking and reasoning.
feedback, and encouraging relaxation
A female client admitted to an acute care C. Impaired urinary elimination
facility after a car accident develops signs D. Risk for injury
and symptoms of increased intracranial
pressure (ICP). The client is intubated and The nurse is performing a mental status
placed on mechanical ventilation to help examination on a male client diagnosed with
reduce ICP. To prevent a further rise in ICP subdural hematoma. This test assesses which
caused by suctioning, the nurse anticipates of the following?
administering which drug endotracheally
A. Cerebellar function
before suctioning?
B. Intellectual function
A. phenytoin (Dilantin) C. Cerebral function
B. mannitol (Osmitrol) D. Sensory function
C. lidocaine (Xylocaine)
A female client complains of periorbital
D. furosemide (Lasix)
aching, tearing, blurred vision, and
After striking his head on a tree while falling photophobia in her right eye.
from a ladder, a young man age 18 is Ophthalmologic examination reveals a
admitted to the emergency department. He’s small, irregular, nonreactive pupil — a
unconscious and his pupils are nonreactive. condition resulting from acute iris
Which intervention would be the most inflammation (iritis). As part of the client’s
dangerous for the client? therapeutic regimen, the physician
prescribes atropine sulfate (Atropisol), two
A. Give him a barbiturate. drops of 0.5% solution in the right eye twice
B. Place him on mechanical ventilation. daily. Atropine sulfate belongs to which
C. Perform a lumbar puncture. drug classification?
D. Elevate the head of his bed.
A. Parasympathomimetic agent
B. Sympatholytic agent
When obtaining the health history from a
C. Adrenergic blocker
male client with retinal detachment, the
nurse expects the client to report: D. Cholinergic blocker

A. light flashes and floaters in front of Emergency medical technicians transport a

the eye. 27-year-old iron worker to the emergency

B. a recent driving accident while department. They tell the nurse, “He fell

changing lanes. from a two story building. He has a large

contusion on his left chest and a hematoma
C. headaches, nausea, and redness of
in the left parietal area. He has a compound
the eyes.
fracture of his left femur and he’s comatose.
D. frequent episodes of double vision.
We intubated him and he’s maintaining an
Which nursing diagnosis takes highest arterial oxygen saturation of 92% by pulse
priority for a client with Parkinson’s crisis? oximeter with a manual-resuscitation bag.”
Which intervention by the nurse has the
A. Imbalanced nutrition: Less than highest priority?
body requirements
B. Ineffective airway clearance A. Assessing the left leg
B. Assessing the pupils
 C. Placing the client in few steps; with each step, the client’s feet
Trendelenburg’s position make a half circle. To document the client’s
D. Assessing level of consciousness gait, the nurse should use which term?

An auto mechanic accidentally has battery A. Ataxic

acid splashed in his eyes. His coworkers B. Dystrophic
irrigate his eyes with water for 20 minutes, C. Helicopod
and then take him to the emergency D. Steppage
department of a nearby hospital, where he
receives emergency care for corneal injury. A physician diagnoses a client with
The physician prescribes dexamethasone myasthenia gravis, prescribing
(Maxidex Ophthalmic Suspension), two pyridostigmine (Mestinon), 60 mg P.O.
drops of 0.1% solution to be instilled every 3 hours. Before administering this
initially into the conjunctival sacs of both anticholinesterase agent, the nurse reviews
eyes every hour; and polymyxin B sulfate the client’s history. Which preexisting
(Neosporin Ophthalmic), 0.5% ointment to condition would contraindicate the use of
be placed in the conjunctival sacs of both pyridostigmine?
eyes every 3 hours. Dexamethasone exerts
A. Ulcerative colitis
its therapeutic effect by:
B. Blood dyscrasia
A. increasing the exudative reaction of C. Intestinal obstruction
ocular tissue. D. Spinal cord injury
B. decreasing leukocyte infiltration at
the site of ocular inflammation.
C. inhibiting the action of carbonic
Nurse Marty is monitoring a client for
anhydrase.
adverse reactions to dantrolene (Dantrium).
D. producing a miotic reaction by
Which adverse reaction is most common?
stimulating and contracting the sphincter
muscles of the iris. A. Excessive tearing
B. Urine retention
Nurse Amber is caring for a client who
C. Muscle weakness
underwent a lumbar laminectomy 2 days
D. Slurred speech
ago. Which of the following findings should
the nurse consider abnormal?
A female client who was found unconscious
at home is brought to the hospital by a
A. More back pain than the first
rescue squad. In the intensive care unit, the
postoperative day
nurse checks the client’s oculocephalic
B. Paresthesia in the dermatomes
(doll’s eye) response by:
nearthe wounds
C. Urine retention or incontinence A. introducing ice water into the
D. Temperature of 99.2° F (37.3° C) external auditory canal.
B. touching the cornea with a wisp of
A male client in the emergency department
cotton.
has a suspected neurologic disorder. To
C. turning the client’s head suddenly
assess gait, the nurse asks the client to take a
while holding the eyelids open.
 D. shining a bright light into the pupil. the following symptoms would the nurse
expect to find?
While reviewing a client’s chart, the nurse
notices that the female client has myasthenia A. Vision changes
gravis. Which of the following statements B. Absent deep tendon reflexes
about neuromuscular blocking agents is true C. Tremors at rest
for a client with this condition? D. Flaccid muscles

A. The client may be less sensitive to

The nurse is caring for a male client
the effects of a neuromuscular
diagnosed with a cerebral aneurysm who
blocking agent.
reports a severe headache. Which action
B. Succinylcholine shouldn’t be used;
should the nurse perform?
pancuronium may be used in a lower
dosage. A. Sit with the client for a few minutes.
C. Pancuronium shouldn’t be used; B. Administer an analgesic.
succinylcholine may be used in a C. Inform the nurse manager.
lower dosage. D. Call the physician immediately.
D. Pancuronium and succinylcholine
both require cautious During recovery from a cerebrovascular
administration. accident (CVA), a
female client is given nothing by mouth, to
help prevent aspiration. To determine when
A male client is color blind. The nurse
the client is ready for a liquid diet, the nurse
understands that this client has a problem assesses the client’s swallowing ability once
with: each shift. This assessment evaluates:
A. cranial nerves I and II.
A. rods. B. cranial nerves III and V.
B. cones. C. cranial nerves VI and VIII.
C. lens. D. cranial nerves IX and X.
D. aqueous humor.

A female client who was trapped inside a car 1. A client admitted to the hospital with a
for hours after a head-on collision is rushed subarachnoid hemorrhage has complaints of
to the emergency department with multiple severe headache, nuchal rigidity, and
injuries. During the neurologic examination, projectile vomiting. The nurse knows
the client responds to painful stimuli with lumbar puncture (LP) would be
decerebrate posturing. This finding indicates contraindicated in this client in which of the
damage to which part of the brain? following circumstances?

A. Diencephalon A. Vomiting continues

B. Medulla B. Intracranial pressure (ICP) is
C. Midbrain increased
D. Cortex C. The client needs mechanical
ventilation
The nurse is assessing a 37-yearold client D. Blood is anticipated in the
diagnosed with multiple sclerosis. Which of cerebrospinal fluid (CSF)
2. A client with a subdural hematoma 1. Bradycardia
becomes restless and confused, with dilation 2. Large amounts of very dilute urine
of the ipsilateral pupil. The physician orders 3. Restlessness and confusion
mannitol for which of the following 4. Widened pulse pressure
reasons?
7. Problems with memory and learning
A. To reduce intraocular pressure would relate to which of the following
B. To prevent acute tubular necrosis lobes?
C. To promote osmotic diuresis to
decrease ICP 1. Frontal
D. 4. To draw water into the vascular 2. Occipital
system to increase blood pressure 3. Parietal
4. Temporal
3. A client with subdural hematoma was
given mannitol to decrease intracranial 8. While cooking, your client couldn’t feel
pressure (ICP). Which of the following the temperature of a hot oven. Which lobe
results would best show the mannitol was could be dysfunctional?
effective?
1. Frontal
1. Urine output increases 2. Occipital
2. Pupils are 8 mm and nonreactive 3. Parietal
3. Systolic blood pressure remains at 4. Temporal
150 mm Hg
4. BUN and creatinine levels return to 9. The nurse is assessing the motor function
normal of an unconscious client. The nurse would
plan to use which of the following to test the
4. Which of the following values is client’s peripheral response to pain?
considered normal for ICP?
1. Sternal rub
1. 0 to 15 mm Hg 2. Pressure on the orbital rim3.
2. 25 mm Hg Squeezing the sternocleidomastoid
3. 35 to 45 mm Hg muscle
4. 120/80 mm Hg 4. Nail bed pressure

5. Which of the following symptoms 10. The client is having a lumbar puncture
may occur with a phenytoin level of performed. The nurse would plan to place
32 mg/dl? the client in which position for the
procedure?
1. Ataxia and confusion
2. Sodium depletion A. Side-lying, with legs pulled up
3. Tonic-clonic seizure and head bent down onto the
4. Urinary incontinence chest
B. Side-lying, with a pillow under
6. Which of the following signs and the hip
symptoms of increased ICP after head C. Prone, in a slight Trendelenburg’s
trauma would appear first? position
11. A nurse is assisting with caloric testing responds based on the knowledge that the
of the oculovestibular reflex of an human body typically and automatically
unconscious client. Cold water is injected responds to pain first with attempts to:
into the left auditory canal. The client
exhibits eye conjugate movements toward 1. Tolerate the pain

the left followed by a rapid nystagmus 2. Decrease the perception of pain

toward the right. The nurse understands that 3. Escape the source of pain
this indicates the client has:
18. The nurse is assessing a child diagnosed
1. A cerebral lesion with a brain tumor. Which of the following
2. A temporal lesion signs and symptoms would the nurse expect

3. An intact brainstem the child to demonstrate? Select all that

apply.
4. Brain death

1. Head tilt
12. The nurse is caring for the client with
2. Vomiting
increased intracranial pressure. The nurse
would note which of the following trends in 3. Polydipsia

vital signs if the ICP is rising? 4. Lethargy

5. Increased appetite
A. Increasing temperature, 6. Increased pulse
increasing pulse, increasing
respirations, decreasing blood 1. =
pressure.
B. Increasing temperature,
21. A nurse is reviewing the record of a
decreasing pulse, decreasing
respirations, increasing blood child with increased ICP and notes that the
pressure. child has exhibited signs of decerebrate
C. Decreasing temperature, posturing. On assessment of the child, the
decreasing pulse, increasing nurse would expect to note which of the
respirations, decreasing blood
following if this type of posturing was
pressure.
D. Decreasing temperature, present?
increasing pulse, decreasing
respirations, increasing blood 1. Abnormal flexion of the upper
pressure. extremities and extension of the lower
13. The nurse is evaluating the status of a extremities
client who had a craniotomy 3 days ago. The 2. Rigid extension and pronation of
nurse would suspect the client is developing the arms and legs
meningitis as a complication of surgery if 3. Rigid pronation of all extremities
the client exhibits:
4. Flaccid paralysis of all extremities

1. A positive Brudzinski’s sign

22. Which of the following assessment data
2. A negative Kernig’s sign
indicated nuchal rigidity?
3. Absence of nuchal rigidity
4. A Glascow Coma Scale score of 15 1. Positive Kernig’s sign
2. Negative Brudzinski’s sign
14. A client is arousing from a coma and 3. Positive homan’s sign
keeps saying, “Just stop the pain.” The nurse
4. Negative Kernig’s sign
10-item examination about Neurological 1. Pulse
Disorders 2. Respirations
3. Blood pressure
1. Regular oral hygiene is an essential
4. Temperature
intervention for the client who has had a
stroke. Which of the following nursing 5. What is a priority nursing assessment
measures is inappropriate when providing in the first 24 hours after admission of
oral hygiene? the client with a thrombotic stroke?

1. Placing the client on the back with a 1. Cholesterol level

small pillow under the head. 2. Pupil size and pupillary response
2. Keeping portable suctioning equipment at 3. Vowel sounds
the bedside. 4. Echocardiogram
3. Opening the client’s mouth
with a padded tongue blade. 6. What is the expected outcome of
4. Cleaning the client’s mouth thrombolytic drug therapy?
and teeth with a toothbrush.
1. Increased vascular permeability.
2. A 78 year old client is admitted to the 2. Vasoconstriction.
emergency department with numbness and 3. Dissolved emboli.
weakness of the left arm and slurred speech. 4. Prevention of hemorrhage
Which nursing intervention is priority?
7. The client diagnosed with atrial
1. Prepare to administer recombinant tissue fibrillation has experienced a transient
plasminogen activator (rt-PA). 2. Discuss the ischemic attack (TIA). Which medication
precipitating factors that caused the would the nurse anticipate being ordered for
symptoms. the client on discharge?
3. Schedule for A STAT computer
tomography (CT) scan of the head. 4. 1. An oral anticoagulant medication.
Notify the speech pathologist for an 2. A beta-blocker medication.
emergency consult. 3. An anti-hyperuricemic medication.
4. A thrombolytic medication.
3. A client arrives in the emergency
department with an ischemic stroke and 8. Which client would the nurse identify as
receives tissue plasminogen activator (t-PA) being most at risk for experiencing a CVA?
administration. Which is the priority nursing
1. A 55-year-old African American
assessment?
male.
1. Current medications. 2. An 84-year-old Japanese female.
2. Complete physical and history. 3. A 67-year-old Caucasian male.
3. Time of onset of current stroke. 4. A 39-year-old pregnant female.
4. Upcoming surgical procedures.
9. Which assessment data would indicate to
4. During the first 24 hours after the nurse that the client would be at risk for
thrombolytic therapy for ischemic stroke, a hemorrhagic stroke?
the primary goal is to control the client’s:
 1. A blood glucose level of 480 mg/dl.
2. A right-sided carotid bruit.
The nurse is caring for a patient who was
3. A blood pressure of 220/120 mmHg.
given pain medication before leaving the
4. The presence of bronchogenic PACU. Upon returning to her room, the
carcinoma. patient states that she is experiencing pain
and requests more pain medication. Which
10. The nurse and unlicensed assistive is the best action for the nurse to take?
personnel (UAP) are caring for a client with 􏰁 A. Tell the patient that she must wait 4
hours for more pain medication.
right-sided paralysis. Which action by the
􏰁 B. Give one-half of the ordered as-needed
UAP requires the nurse to intervene? dose.
􏰁 C. Document the patient’s pain.
A. The assistant places a gait belt 􏰁 D. Notify the practitioner that the
around the client’s waist prior to patient is continuing to experience pain.
ambulating.
B. The assistant places the client on
the back with the client’s head to The nurse is evaluating a patient
the side. postoperatively for infection. Which of the
C. The assistant places her hand following would be most indicative of
infection?
under the client’s right axilla to
􏰁 A. The presence of an indwelling urinary
help him/her move up in bed. catheter
D. The assistant praises the client 􏰁 B. A rectal temperature of 100° F (37.8°
for attempting to perform ADL’s C)
􏰁 C. Redness, warmth, and tenderness in
independently.
the incision area
􏰁 D. A white blood cell (WBC) count of
PERI OPERATIVE NURSING - 8,000/mL
LIPINCOTT

A patient undergoes a surgical procedure

The nurse is caring for a patient with a
that requires the use of general anesthesia.
postoperative wound evisceration. Which
Following general anesthesia, the patient is
action should the nurse perform first?
most at risk for:
􏰁 A. Explain to the patient what is
􏰁 A. atelectasis.
happening, and provide support.
􏰁 B. anemia.
􏰁 B. Cover the protruding organs with
􏰁 C. dehydration.
sterile gauze moistened with sterile saline
􏰁 D. peripheral edema.
solution.
􏰁 C. Push the protruding organs back into
the abdominal cavity.
The nurse is administering preoperative
􏰁 D. Ask the patient to drink as much fluid
medication to a patient going to the
as possible.
operating room for an aortobi-femoral
bypass. After administering preoperative
medication to the patient, the nurse should:
􏰁 A. allow him to walk to the bathroom
A patient in the postoperative phase of
unassisted.
abdominal surgery is to advance his diet as
􏰁 B. place the bed in low position with
tolerated. The patient has tolerated ice chips
the side rails up.
and a clear liquid diet. As the next step, the
􏰁 C. tell him that he’ll be asleep before he
nurse would expect the patient to advance
leaves for surgery.
to:
􏰁 D. take his vital signs.
􏰁 A. fluid restriction. 􏰁 A. Give oxygen continuously at 3
􏰁 B. a full-liquid diet. L/minute.
􏰁 C. a general diet. 􏰁 B. Have the patient cough and
􏰁 D. a soft diet. deep-breathe every 4 hours.
􏰁 C. Have the patient use an incentive
spirometer every hour.
The patient’s intake and output record 􏰁 D. Get the patient out of bed to a chair
contains the following information: milk, every day.
180 mL; orange juice, 60 mL; one serving
scrambled eggs; one slice toast; one can
Ensure oral nutritional supplement, 240 mL; PERIOPERATIVE - SAUNDERS
I.V. dextrose 5% in water at 100 mL/hour;
50 mL water after twice daily medications.
Medications are given at 9:00 a.m. and 9:00 1. The nurse has just reassessed the
p.m. What is the patient’s total intake for the condition of a postoperative client who was
7 a.m. to 3 p.m. shift? admitted 1 hour ago to the surgical unit. The
􏰁 A. 1,000 mL nurse plans to monitor which parameter
􏰁 B. 1,250 mL most carefully during the next hour?
􏰁 C. 1,330 mL 1. Urinary output of 20 mL/hr
􏰁 D. 1,380 mL 2. Temperature of 37.6° C (99.6° F)
3. Blood pressure of 100/70 mm Hg
Which action is included in the principles of 4. Serous drainage on the surgical dressing
asepsis?
􏰁 A. Maintaining a sterile environment 2. The nurse is teaching a client about
􏰁 B. Keeping the environment as clean as coughing and deep-breathing techniques to
possible prevent postoperative complications. Which
􏰁 C. Testing for microorganisms in the statement is most appropriate for the nurse
environment to make to the client at this time as it relates
􏰁 D. Cleaning an environment until it is free to these techniques?
from germs 1. “Use of an incentive spirometer will
help prevent pneumonia.”
2. “Close monitoring of your oxygen
On the first day after thoracotomy, the saturation will detect hypoxemia.”
nurse’s assessment of the patient reveals a 3. “Administration of intravenous uids will
temperature of 100° F (37.8° C), a heart rate prevent or treat uid imbalance.”
of 96 beats/minute, blood pressure of 136/86 4. “Early ambulation and administration of
mm Hg, and shallow respirations of blood thinners will prevent pulmonary
24 breaths/minute, with rhonchi heard at the embolism.”
lung bases. The patient complains of
incisional pain. Which nursing action takes
priority? 3. The nurse is creating a plan of care for a
􏰁 A. Medicating the patient for pain client scheduled for surgery. The nurse
􏰁 B. Helping the patient out of bed would include which activity in the nursing
􏰁 C. Administering ibuprofen (Motrin) as care plan for the client on the day of
ordered to reduce fever surgery?
􏰁 D. Encouraging the patient to cough and 1. Avoid oral hygiene and rinsing with
deep-breathe mouthwash.
2. Verify that the client has not eaten for the
last 24 hours.
3. Have the client void immediately before
10. Which intervention is most important to going into surgery.
include in a nursing care plan for a patient 4. Report immediately any slight increase in
with atelectasis? blood pressure or pulse.
 1. “Aspirin can cause bleeding after
4. A client with a gastric ulcer is scheduled surgery.”
for surgery. The client cannot sign the 2. “Aspirin can cause my ability to clot
operative consent form because of sedation blood to be abnormal.”
from opioid analgesics that have been 3. “I need to continue to take the aspirin
administered. The nurse would take until the day of surgery.”
which most appropriate action in the care of 4. “I need to check with my doctor about the
this client? need to stop the aspirin before the scheduled
1. Obtain a court order for the surgery. surgery.”
2. Have the charge nurse sign the informed
consent immediately.
3. Send the client to surgery without the 8. The nurse assesses a client’s surgical
consent form being signed. incision for signs of infection. Which
4. Obtain a telephone consent from a finding by the nurse would be interpreted as
family member, following agency policy. a normal finding at the surgical site?
1. Hard reddened skin
2. Serous drainage
5. A preoperative client expresses anxiety to 3. Purulent drainage
the nurse about upcoming surgery. Which 4. Warm, tender skin
response by the nurse is most likely to
stimulate further discussion between the
client and the nurse? 9. The nurse is monitoring the status of a
1. “If it’s any help, everyone is nervous postoperative client in the immediate
before surgery.” postoperative period. The nurse would
2. “I will be happy to explain the entire become most concerned with which sign
surgical procedure to you.” that could indicate an evolving
3. “Can you share with me what you’ve complication?
been told about your surgery?” 1. Increasing restlessness
4. “Let me tell you about the care you’ll 2. A pulse of 86 beats per minute
receive after surgery and the amount of pain 3. Blood pressure of 110/70 mm Hg
you can anticipate.” 4. Hypoactive bowel sounds in all four
quadrants
6. The nurse is conducting preoperative
teaching with a client about the use of an
incentive spirometer. The nurse needs to 10. A client who has had abdominal surgery
include which piece of information in complains of feeling as though “something
discussions with the client? gave way” in the incisional site. The nurse
1. Inhale as rapidly as possible. removes the dressing and notes the presence
2. Keep a loose seal between the lips and the of a loop of bowel protruding through the
mouthpiece. incision. Which interventions would
3. After maximum inspiration, hold the the nurse take? Select all that apply.
breath for 15 seconds and exhale. 1. Contact the surgeon.
4. The best results are achieved when 2. Instruct the client to remain quiet.
sitting up or with the head of the bed 3. Prepare the client for wound closure.
elevated 45 to 90 degrees. 4. Document the findings and actions
taken.
5. Place a sterile saline dressing and ice
7. The nurse has conducted preoperative packs over the wound.
teaching for a client scheduled for surgery in 6. Place the client in a supine position
1 week. The client has a history of arthritis without a pillow under the head.
and has been taking acetylsalicylic acid. The
nurse determines that the client needs 11. A client who has undergone
additional teaching if the client makes which preadmission testing has had blood drawn
statement? for serum laboratory studies, including a
complete blood count, coagulation studies,
and electrolytes and creatinine levels.
Which laboratory result would be reported
to the surgeon’s office by the nurse,
knowing that it could cause surgery to be
postponed?
1. Hemoglobin, 8.0 g/dL (80 mmol/L)
2. Sodium, 145 mEq/L (145 mmol/L)
3. Serum creatinine, 0.8 mg/dL (70.6
mcmol/L)
4. Platelets, 210,000 cells/mm3
(210 × 109/L)

12. The nurse receives a telephone call from

the postanesthesia care unit, stating that a
client is being transferred to the surgical
unit. The nurse plans to take which action rst
on arrival of the client?
1. Assess the patency of the airway.
2. Check tubes or drains for patency.
3. Check the dressing to assess for bleeding.
4. Assess the vital signs to compare with
preoperative measurements.

13. The nurse is reviewing a surgeon’s

prescription sheet for a preoperative client
that states that the client must be nothing by
mouth (NPO) after midnight. The nurse
needs to call the surgeon to clarify that
which medication would be given to the
client and not withheld?
1. Prednisone
2. Ferrous sulfate
3. Cyclobenzaprine
4. Conjugated estrogen